Introduction

Ankyloglossia (Tongue-Tie) is a congenital anomaly characterised by the presence of a short or tight lingual frenum that serves as an attachment of the base of the tongue to the floor of the mouth, restricting normal tongue movement.¹ This condition has been linked to several functional limitations, including difficulties with breastfeeding, speech articulation, oral hygiene, and psychosocial concerns. Globally, the prevalence ranges from 0.1% to 10.7% in newborns, excluding children, teenagers and adults.² In the UK, the incidence ranges from 4% to 11%, with a likelihood of around 60000 out of 680000 infants being born with the condition each year.³ Infants having this condition may face breastfeeding difficulties such as poor latching, irritability during breastfeeding and failure to thrive. Additionally, mothers might face challenges including pain while breastfeeding, deficient milk secretion and sometimes infection and ulceration on nipples. Delayed diagnosis and care adversely impact children's speech and language development, eventually affecting their mental health.² Therefore, the objective of this article is to explore the association and impact of tongue-tie on speech and language milestones in newborns.

Life of tongue 

Everything just seems to be at the tip of our tongue. Our tongue is an extremely flexible sensory organ made of movable muscles, rich in blood and nerve supply. Its oblong shape, as shown in Figure 1, allows it to fill up the entire cavity of our mouths respectively. Tongue facilitates in sucking, chewing, grinding, pressing, salivating, swallowing, tasting, feeling, speaking and fighting infections.

The presence of papillae on the tongue aids in taste perception as they differentiate between sweet, salty, bitter, sour and umami flavours. The tongue has been reported as one of the important speech articulators that helps shape sounds by interacting with the teeth, alveolar ridge, hard and soft palate and lips. Different parts and movements of the tongue articulate different sounds.

Tip of the tongue helps produce Sounds like t, d, n, s, and z, Blade of the tongue aids in sounds like f, sh and 3 (as in "measure"), Dorsum (back) of the tongue in sounds like k and g and Lateral tongue movements aid in clear articulation of l. 

Tongue restrictions, such as Tongue-Tie, limits tongue movement and flexibility, which can cause difficulty in speech articulations as well as pronunciation.⁴ Let's take a look at how severe this condition can be.

Figure 1: This figure illustrates the Anatomy of the tongue: Tip of the tongue, Groove, Papilla (Circumvallate, Foliate and Fungiform). Base / Surface / Dorsum of the tongue. Created in  https://BioRender.com.⁴

Classification

Ankyloglossia can be classified broadly based attachment of the tongue to the floor of the mouth: Authors have documented classification as follows:²

1. Based on the site of restriction:
   • Anterior Ankyloglossia
   • Posterior Ankyloglossia
2. Based on the restriction
   • Partial Ankyloglossia
   • Complete Ankyloglossia
3. Based on the severity of the restriction
   • Class I: Mild
   • Class II: Moderate
   • Class III: Severe

Causes                                                                        

The exact cause of tongue-tie remains unknown till date. Authors have reported different predisposing factors that can cause tongue-tie. However, further research is needed to understand the roots of this condition.

• Genetic (Autosomal Dominant) 
• X-linked cleft palate syndrome 
• Rare syndromes, including Kindler, Opitz, and Van Der Woude 
• Alcohol consumption, intake of cocaine during pregnancy²

Effect of tongue-tie on oral function                    

Breastfeeding and early solid intake challenges

Poor latching might result in deficient breast milk intake. Improper sucking may lead to maternal nipple pain, infection, or ulceration. Inadequate intake might increase the frequency of feeding sessions. ^{5, 6}

Swallowing and chewing challenges

Limited tongue movement can cause difficulty in moving food within the mouth, increasing the risk of gagging and choking on the food. Additionally, there is a delay in transition to solid food owing to their compromised oral-motor coordination.⁷

Speech and language development challenges 

Children with tongue-tie may have the following speech-related challenges:

• Alveolar Sound t, d, n, l: These sounds require the tongue to touch the alveolar ridge, which can be challenging with limited mobility.
• Sibilant Sounds s, z: Proper airflow control for these sounds may be disrupted, leading to articulation mistakes.
• Liquid Sounds l, r: The inability to lift or curl the tongue properly might result in distorted or missing sounds.
• Velar Sounds k, g: Although less common, severe tongue-tie may impact these sounds as well.⁸

Normal v/s tongue tie speech milestones

Table 1: The table above presents the key challenges faced by a newborn with tongue-tie during speech development. Furthermore, it illustrates the differences in speech development between infants with tongue-tie and those without, providing a comparative analysis of their developmental trajectories ^{2, 8} 

Decision making: for parents' understanding 

Step 1: Identify the condition

Does your newborn have trouble with breast or bottle feeding?

• NO: Proceed to Step 2 
• YES: Consult a Paediatrician or Lactation specialist

Does your child have difficulty sticking out the tongue or moving it freely?

• NO: Proceed to Step 2
• YES: Consult a Pedodontist or Paediatrician, or ENT specialist

Is your child experiencing speech development delays or difficulty with pronunciation?

• NO: Proceed to Step 2 
• YES: Consult a Speech and Language Therapist and Paediatrician

Is your child able to chew and gulp solid food without any complaints? Are there any gagging or trouble moving food around complaints? 

• NO: If no concerns, Monitor continuously
• YES: Consult a Pedodontist or Paediatrician, or ENT specialist

Step 2: Evaluate the severity of the condition and take action!

Picture-based assessment evaluation tool, TABBY (Tongue-tie and Breastfed Babies) and Bristol Tongue tie assessment tool were developed by NHS Bristol in 2017 to rate the severity of Ankyloglossia.⁹

Table 2: The above table depicts the Bristol Tongue tie assessment tool criteria to evaluate the severity of Tongue tie. Scoring (0-2) is directly proportional to the severity.⁹

Uncovering the overall impact

Oral-motor development and coordination

Chewing, grinding and swallowing greatly depend on tongue movement. Limited tongue mobility and poor coordination may adversely impact saliva flow and swallowing.⁷

Psychosocial and Emotional Impact

Difficulties in communication, especially pronunciation, can lead to frustration and increased introversion, ultimately reducing social interactions. If left unaddressed, this may impact confidence and hinder personality development. Additionally, speech delays can have long-term effects on reading and writing skills. Pronouncing new words, particularly those requiring extensive tongue movements, may also pose a challenge.¹⁰

Management of tongue-tie

Non-surgical interventions 

• Speech therapy helps strengthen oral muscles and improve speech articulation. 
• Oral exercises promote tongue exercise, mobility, and flexibility
• Lactation specialists assist in adapting modern feeding techniques to improve latching and overcome challenges with deficient breast or bottle milk intake

Surgical interventions

• Patient assessment: Evaluating symptoms (feeding difficulties and speech articulation), performing physical examination (tongue mobility and lingual frenum attachment) and discussing risks, benefits, alternatives and side effects related to Frenectomy and Frenotomy.
• Preparation phase: Obtaining informed consent is the most important step. An aseptic surgical environment must be maintained throughout the procedure. Ensuring proper positioning:
  • Infant in swaddled position
  •  An adult in a reclined position

Procedure

Table 3: The above table highlights the key differences between the different surgical procedures performed to manage Tongue-tie.^{12, 13}

Postoperative healing

• Seek healthcare professional advice to take pain relief medications (lactating mothers and breastfeeding)
• To prevent scarring and reattachment, educational awareness needs to be spread among parents, guardians and caregivers.
• Regular follow-ups to monitor healing and function restoration.

Conclusion

Tongue-tie, a birth defect characterised by limited tongue movement, can have a significant impact on speech and language development, depending on its severity. Early detection and appropriate intervention are vital in mitigating potential delays in communication skills and other developmental milestones. Without proper guidance, children may have difficulty with speech articulation, pronunciation, and verbal expression, affecting their confidence, social relationships, and literacy abilities. Addressing tongue-tie with appropriate treatment options, such as speech therapy or surgical correction when needed, can enhance speech clarity, support normal language acquisition, and improve overall patient well-being. Growing awareness of this condition enables parents and healthcare professionals to make informed decisions, ensuring optimal communication outcomes for affected infants, children and adults.

FAQs

What is tongue tie, and how does it impact speech development?

Tongue tie (ankyloglossia) is a congenital condition in which the lingual frenulum is abnormally short or tight, limiting tongue mobility. This can impair a child's ability to produce certain sounds, pronounce words clearly, and develop normal speech patterns.

At what age may tongue-tie be diagnosed?

Tongue-tie can be detected at birth during a regular neonatal examination, or later when feeding or speech difficulties become evident.   Early detection is recommended to determine whether or not intervention is necessary. 

How does tongue-tie affect language milestones in children?

Children with tongue-tie can experience delay in speech  development, difficulty in pronouncing certain consonants, and reduced verbal communication confidence. These challenges can have an impact on early language milestones such as babbling, word formation, and sentence construction.

What sounds are most affected by tongue tie?

Sounds that require tongue elevation and movement, such as "l", "r", "t", "d", "n",”f”, "s" and "z" are often difficult for children with tongue-tie to pronounce correctly.

Will tongue-tie impact literacy skills?

Indeed, tongue-tie-induced speech delays can cause difficulty with pronunciation, which is necessary for reading and writing. Children with unresolved speech issues may have difficulty with spelling, identifying words, and comprehension of text. 

How can speech therapy help children with tongue tie?

Speech therapy can help to increase tongue movement, strengthen tongue muscles, and improve articulation capacity.   A Speech and Language Therapist (SALT) can assist children overcome speech challenges related to tongue-tie by offering them exercises and strategies.

What is the long-term impact of unresolved tongue tie on speech?

If not addressed, tongue-tie might result in persistent speech articulation challenges, decreased confidence in verbal communication, and potential academic challenges concerning language and literacy. It could impact social interactions and self-esteem.

How can early intervention favour speech and language outcomes?

Addressing tongue-tie early can help reduce frustration, improve communication skills, and promote overall language development.

What role do parents have in helping their child with tongue tie?

Parents can advocate for an early diagnosis, seek expert guidance, and have their child engage in speech exercises. Encouraging communication and fostering a supportive learning environment can assist children with tongue-tie develop strong language abilities.